Provider Demographics
NPI:1962441238
Name:KERAMATI, MICHAEL M (DO, DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:KERAMATI
Suffix:
Gender:M
Credentials:DO, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16550 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2055
Mailing Address - Country:US
Mailing Address - Phone:818-990-5588
Mailing Address - Fax:818-990-5589
Practice Address - Street 1:16550 VENTURA BLVD
Practice Address - Street 2:214
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2004
Practice Address - Country:US
Practice Address - Phone:818-990-5588
Practice Address - Fax:818-990-5589
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX89060Medicaid
CA00AX89060Medicaid
20A8906Medicare ID - Type Unspecified